Analysis Sheer to Starboard Because the pilot sat in the starboard captain's chair at the IBS and the autopilot control panel is located on the starboard side of the central console, the pilot was the closest to this panel. It was therefore convenient for him to operate the autopilot when set course changes were required (that is, press the arrow-inscribed membrane keys). Without explicitly telling the pilot what to do, the master explained the basic operation of the autopilot, and the pilot assumed the role without further discussion. No helmsman was requested by the pilot, nor was the service of a helmsman offered by the master.On the Pilotstar D autopilot control panel, the Auto On/Off, Track and Trim Man function membrane keys are identical in size and touch as the arrow (course alteration) keys. The proximity of the Trim Man function key to the starboard arrow key and the vessel's behaviour in the events leading up to the grounding suggest that the pilot inadvertently pushed the Trim Man key instead of the starboard arrow key, just prior to the vessel turning abruptly to starboard.By pushing this function key, the autopilot was deactivated, the system changed to manual control and to NFU mode. In manual and NFU mode, the set course reading is deactivated and the reading does not change. All further attempts to correct course to steer, using the arrow keys, were now actual rudder commands. The sequence of events indicates that the actions of the pilot to regain control of the rudder and steer 230 were in fact now causing the rudder to move increasingly to starboard. This is consistent with the vessel's rapid swing to starboard and would account for the 80 deviation of the course.The pilot's primary task was the conduct of the vessel. When the autopilot did not function as intended and the vessel developed a swing to starboard, it increased his workload. Given that his knowledge of the system was limited, when his scanning of the autopilot LCD screen did not provide him with the answer to what was happening, his attention became divided between the conduct of the vessel and the operation of the autopilot to regain control of the vessel. In other words, the swing to starboard prevented him from focussing more attention on why the autopilot did not function as expected.Generally, performance standards of modern equipment are excellent; however, if the operator does not comprehend the significance of the information available or presented, a potentially dangerous situation may develop.9In today's marine environment, there are many manufacturers of navigation equipment worldwide. While, generally, there are performance standards governing how the equipment functions, the ergonomics and functionality of the equipment control systems are not standardized and there is no regulatory mandatory training to alleviate this problem.Being unfamiliar with this make of autopilot, the pilot did not understand why the vessel did not respond to his orders, and he was not able to correct the situation or to explain to the OOW what he had done to deactivate the system. Emergency Override Steering System Before the OOW switched to the follow-up mode at the steering station (wheel) and started a second steering pump, the OOW unsuccessfully tried to correct the situation with the autopilot controls. The OOW finally used the wheel at the steering control stand, but this action was carried out too late.In high-density traffic or restricted waterways, a steering gear failure or autopilot malfunction can be catastrophic. Sometimes it turns out that all that was necessary to avert the danger was a firm push at the correct moment on a simple control button.10 It is necessary, therefore, for an OOW to be fully familiar with the onboard steering system, including all the controls. Only through training at regular intervals will the OOW maintain an understanding of the system and take immediate corrective action in an emergency. In this occurrence, the FFU joystick was not actuated to override the starboard helm command on the autopilot system. Navigation Equipment Familiarization The IBS has some similarities to pilot-copilot aircraft console arrangements. The navigation equipment is so arranged that controls are shared by the two operators. As only two people are involved in the operation, this model requires that the two navigators be duly qualified and familiar with the onboard navigation equipment.In comparison to aircraft pilots, who must follow simulator training to be proficient using a specific aircraft and its equipment, this type of training is neither available nor possible for navigators and marine pilots because of the non-standardization of navigation equipment. In this occurrence, the bridge team consisted of two professional mariners, who were expected to work as a team and conduct the vessel safely up the river. Both were qualified for the job to be done, but their equipment-familiarization training was less than adequate in the areas of basic operation and emergency override. As part of an overall training program, navigation equipment-familiarization training contributes to transportation safety. Bridge Crewing in Pilotage Waters and Safety The International Convention for the Safety of Life at Sea, 1974,11 the International Safety Management Code (ISM Code), and the Code of Nautical Procedures and Practices all indicate that automatic steering should be switched to manual steering in sufficient time to allow for a potentially hazardous situation to be safely dealt with, particularly in areas of high-traffic density, restricted visibility, and other hazardous navigational situations.If the only persons on the bridge are the pilot and the OOW in restricted waters, the OOW would have to take over the steering manually, if necessary, thus depriving him of his primary role until a helmsman could be acquired. Similarly, if the pilot was involved in steering, he/she would be deviating from his/her principle functions. In this instance, none of the three ratings was called to perform steering duty. Given the crewing situation on the bridge and as requested by the master, the pilot undertook the task of steering the vessel by means of the autopilot. From a best-practice outlook, and given the level of automation, bridge ergonomics and the pilot's limited knowledge of this type of autopilot, it should not have been the duty or the obligation of the pilot to steer the ship using this equipment. Despite the duties and obligations of a pilot, his presence on board does not relieve the master or officer in charge of the watch from their duties and obligations for the safety of the ship. . . .12 The duties of steering and the use/activation of the autopilot are responsibilities that should rest with a member of the crew who is familiar with the equipment and who can safely accomplish the task.The need to have the bridge adequately crewed for safe transit of a vessel has been recognized by the Canadian administration. For a Canadian vessel of a similar size, the composition of a deck watch under the Crewing Regulationsis specific, requiring two persons adequately trained for watchkeeping duties. However, the STCW does not specifically refer to additional personnel, as this is left to the discretion of the individual Flag State administrations. Additionally, recognizing that prompt action may be required under certain circumstances, the services of a qualified helmsman are required at all times to take over steering control of a ship.13 On a bridge, each navigation team member has specific duties to perform. Under normal operational circumstances at sea, when the autopilot is in use, the designated helmsman may carry out tasks other than steering. In a restricted waterway, however, the presence of the helmsman at the steering station is essential. This was not the case on board the Vaasaborg. Use of Steering Gear Power Units Although not a contributing factor to this occurrence, only one steering pump was in service when the autopilot was changed to manual control.Mariners should consider the importance of complying with the requirements of the International Convention for the Safety of Life At Sea (SOLAS), Regulation19-1, ChapterV, which stipulate that: In areas where navigation demands special caution, ships shall have more than one steering gear power unit in operation when such units are capable of simultaneous operation. No crew member of the Vaasaborg was tasked to steer the vessel, and the pilot undertook to make course set alterations with the autopilot. In trying to change the set course, it is most likely that the pilot inadvertently first pushed the TrimMan function key instead of the starboard arrow (course alteration) key, thereby deactivating the autopilot and switching the system to the non-follow-up mode. When the pilot pressed the starboard arrow key, the helm gradually turned to hard-a-starboard, but the course set reading on the autopilot screen remained the same. By the time that the officer of the watch (OOW) switched the steering control to the follow-up mode at the steering stand, the vessel had commenced a rapid swing to starboard, from which it was not possible to recover before the vessel left the channel and ran aground. The OOW did not employ the emergency override steering system, which may have acted more quickly to correct the situation.Findings as to Causes and Contributing Factors No crew member of the Vaasaborg was tasked to steer the vessel, and the pilot undertook to make course set alterations with the autopilot. In trying to change the set course, it is most likely that the pilot inadvertently first pushed the TrimMan function key instead of the starboard arrow (course alteration) key, thereby deactivating the autopilot and switching the system to the non-follow-up mode. When the pilot pressed the starboard arrow key, the helm gradually turned to hard-a-starboard, but the course set reading on the autopilot screen remained the same. By the time that the officer of the watch (OOW) switched the steering control to the follow-up mode at the steering stand, the vessel had commenced a rapid swing to starboard, from which it was not possible to recover before the vessel left the channel and ran aground. The OOW did not employ the emergency override steering system, which may have acted more quickly to correct the situation. The pilot had not acquired the proficiency and familiarity with the autopilot that was necessary to safely operate it in an emergency situation. At the time of the loss of steering, the OOW was not sufficiently familiar with the autopilot to employ the steering mode most likely to regain control. Although not a factor contributing to the occurrence, only one steering gear pump was in service while the vessel was operating in confined waters.Findings as to Risks The pilot had not acquired the proficiency and familiarity with the autopilot that was necessary to safely operate it in an emergency situation. At the time of the loss of steering, the OOW was not sufficiently familiar with the autopilot to employ the steering mode most likely to regain control. Although not a factor contributing to the occurrence, only one steering gear pump was in service while the vessel was operating in confined waters. Safety Action Taken Transportation Safety Board of Canada In August 2002, Marine Safety Information (MSI) letter 08/02 was forwarded to the Laurentian Pilotage Authority (LPA), the ship owners, the Netherlands Shipping Inspectorate, and a copy to Transport Canada, concerning duties performed by the pilot other than those normally carried out and the use of navigation equipment without proper training. Laurentian Pilotage Authority Upon receiving MSI 08/02, the LPA communicated with the Port of Montral (DistrictNo.1.1) pilots and the two pilot corporations, i.e. Montral-Qubec (DistrictNo.1) and Qubec-Les Escoumins (DistrictNo.2), recommending that the pilots not steer the vessel themselves using an autopilot, but instead request the services of a qualified helmsman. The LPA insists that a qualified deck watch officer and helmsman from the ship's complement be in the wheelhouse in compulsory pilotage waters to steer the vessel. LPA Pilots and Pilot Corporations The Port of Montral pilots are employees of the LPA, and, therefore, their compliance to the LPA recommendations is implicit. The other two corporations, however, initially responded with reservations to the LPA recommendation. After several exchanges of correspondence, in May2004, the Corporation des pilotes du Saint-Laurent central (DistrictNo.1) acknowledged the LPA recommendation by advising its pilots to conform to the recommendation concerning the manipulating of autopilot controls and the presence of a helmsman in the wheelhouse.